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Personal Information

Name:

Address:

City:

State:

Zip:

Day Phone:

Night Phone:

Best Time To Call:

AM
PM

Email Address:

Current Auto Insurance Information

Company Name (not agency):

Policy Expiration Date:

Premium Amount: $

Term:

6 Months
1 Year
Other:

Vehicle Information

(include all cars you or your family members own or lease)

Car #1

Year

Make

Model

Body Type

Vehicle ID# (VIN)

Name of Title Holder

Annual Mileage

Drive to school/work?
Y
N

# of miles (one way)

Airbags
Y
N

Car Alarm
Y
N

If vehicle is kept at an address other than that listed above, please indicate below:

Location City:

State:

Zip:

Car #2

Year

Make

Model

Body Type

Vehicle ID# (VIN)

Name of Title Holder

Annual Mileage

Drive to school/work?
Y
N

# of miles (one way)

Airbags
Y
N

Car Alarm
Y
N

If vehicle is kept at an address other than that listed above, please indicate below:

Location City:

State:

Zip:

Car #3

Year

Make

Model

Body Type

Vehicle ID# (VIN)

Name of Title Holder

Annual Mileage

Drive to school/work?
Y
N

# of miles (one way)

Airbags
Y
N

Car Alarm
Y
N

If vehicle is kept at an address other than that listed above, please indicate below:

Location City:

State:

Zip:

Car #4

Year

Make

Model

Body Type

Vehicle ID# (VIN)

Name of Title Holder

Annual Mileage

Drive to school/work?
Y
N

# of miles (one way)

Airbags
Y
N

Car Alarm
Y
N

If vehicle is kept at an address other than that listed above, please indicate below:

Location City:

State:

Zip:

Liability Limit For ALL Cars

Choose either Bodily InjuryandProperty Damage

Bodily Injury

Property Damage

orSingle Limit

Single Limit

Deductibles and Misc.

Car# 1

Comprehensive Deductible

Collision Deductible

Towing
Yes

Loss of Use
Yes

Car# 2

Comprehensive Deductible

Collision Deductible

Towing
Yes

Loss of Use
Yes

Car# 3

Comprehensive Deductible

Collision Deductible

Towing
Yes

Loss of Use
Yes

Car# 4

Comprehensive Deductible

Collision Deductible

Towing
Yes

Loss of Use
Yes

Driver Information

(include all licensed drivers in your household)

Driver #1

Driver's Name

Drivers License Information

DL#:

State:

Yr's Lic:

Relation

Date of Birth

Soc. Sec. #

Courses Completed Last 3 yrsDrivers Ed: Y
NAccident Prevention: Y
N

Driver #2

Driver's Name

Drivers License Information

DL#:

State:

Yr's Lic:

Relation

Date of Birth

Soc. Sec. #

Courses Completed Last 3 yrsDrivers Ed: Y
NAccident Prevention: Y
N

Driver #3

Driver's Name

Drivers License Information

DL#:

State:

Yr's Lic:

Relation

Date of Birth

Soc. Sec. #

Courses Completed Last 3 yrsDrivers Ed: Y
NAccident Prevention: Y
N

Driver #4

Driver's Name

Drivers License Information

DL#:

State:

Yr's Lic:

Relation

Date of Birth

Soc. Sec. #

Courses Completed Last 3 yrsDrivers Ed: Y
NAccident Prevention: Y
N

Driver History

Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years

Driver

Date

Type of Conviction

Fines
$

Speed Over Limit
mph

Driver

Date

Type of Conviction

Fines
$

Speed Over Limit
mph

Driver

Date

Type of Conviction

Fines
$

Speed Over Limit
mph

Driver

Date

Type of Conviction

Fines
$

Speed Over Limit
mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions below

Driver:

License Suspended or Revoked:
Suspended
Revoked

DUI Conviction For:
Alcohol
Drugs

Driver:

License Suspended or Revoked:
Suspended
Revoked

DUI Conviction For:
Alcohol
Drugs

Driver:

License Suspended or Revoked:
Suspended
Revoked

DUI Conviction For:
Alcohol
Drugs

Driver:

License Suspended or Revoked:
Suspended
Revoked

DUI Conviction For:
Alcohol
Drugs

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years

Driver

Date

Description

Cost
$

Fines
$

Injuries
Yes

At Fault
Yes

Driver

Date

Description

Cost
$

Fines
$

Injuries
Yes

At Fault
Yes

Driver

Date

Description

Cost
$

Fines
$

Injuries
Yes

At Fault
Yes

Driver

Date

Description

Cost
$

Fines
$

Injuries
Yes

At Fault
Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information wherethere was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.One of our representatives will respond to your submission as soon as possible.

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9225 East M-36Whitmore Lake, MI 48189

(888)PIETILA (888-743-8452)

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